Sleep Apnoea - What Is It and What Can We Do About It?

Do you feel very sleepy during the day, despite getting normal amounts of sleep?

Has anyone ever told you that you stop breathing, or gasp for air while you’re asleep?

Do you snore loudly?

If you answer yes to two or more of the questions above, or you know someone that does, read on to find out more about sleep apnoea, and how to treat it.

What is sleep apnoea?

Sleep apnoea is a sleep disorder in which you temporarily stop breathing during sleep, multiple times during the night. The pauses in breathing last at least 10 seconds; long enough for the brain to notice that oxygen levels are low, and that carbon dioxide levels are high. This triggers a move from the deepest stage of sleep into a lighter stage of sleep, when you will start to breathe again. A bed partner may notice sounds like gasping, snorting or choking, but you may still be fast asleep, and completely unaware that your breathing paused.

It’s normal to experience up to a few brief apnoea episodes an hour. Sleep apnoea sufferers can experience hundreds of brief pauses in their breathing every night. The result is that they spend very little time in deep sleep, and end up feeling very sleepy during the day.

What causes sleep apnoea?

The most common type of sleep apnoea occurs when the soft tissues in the upper airways relax during deep sleep and cause a severe narrowing or obstruction; this is called obstructive sleep apnoea, or OSA. The blockage is often caused by the tongue or soft palate falling back against the back wall of the airway. This is more likely to happen when you are lying on your back with your mouth open, so that the jaw falls backwards. Although obstructive sleep apnoea is more common in people who are carrying excess weight, it can affect anyone of any age or body shape.

Central sleep apnoea (CSA) happens when the brain sends a faulty signal to the breathing muscles, and you effectively ‘forget’ to breathe. This can happen as the result of an underlying medical condition, recent exposure to high altitude, or as a side effect of some medication. You can also suffer from a combination of CSA and OSA.

How do I know if I have sleep apnoea?

Obstructive sleep apnoea is thought to affect about 4% of men, and 2% of women, but many remain unaware that they have the condition.

Here are some of the characteristics associated with a higher risk of obstructive sleep apnoea:

●Overweight or obese

●Male gender

●Age 50 and above

●Family history of sleep apnoea

●Thickset neck (neck circumference >40cm)

●Heart disease, diabetes, obesity, chronic obstructive pulmonary disease (COPD)

●Having large tonsils or adenoids

Here are some of the signs and symptoms which can be associated with OSA:

●Loud snoring

●Daytime sleepiness (struggling to keep your eyes open during the day, despite normal amounts of sleep)

●Someone observing you stopping breathing during sleep

●Waking up multiple times during the night

●Irritability, low mood or anxiety

●Morning headaches

●Waking up with a dry mouth

●Forgetfulness

●Decreased interest in sex

You can score your risk of sleep apnoea using the STOP-BANG questionnaire on the British Snoring and Sleep Apnoea Association website (Chung et al 2012).

Although extremely loud snoring is a key risk factor for obstructive sleep apnoea, it is possible to experience OSA without being a loud snorer. In older women in particular, daytime fatigue, restless legs or frequent waking during the night may be the most obvious symptoms. OSA becomes more common for women at and after the menopause, owing to hormonal changes and changes in body composition.

If you suspect that you could have sleep apnoea, speak to your doctor about it. They will try to rule out other likely causes. They are likely to recommend an overnight sleep test, either in a sleep lab or at home. During the test, the levels of oxygen in your blood will be measured using a clip on your finger (pulse oximetry) and your breathing rate will be monitored. You can also order your own home sleep apnoea test privately.

The overnight sleep test will count the average number of apnoeas (pauses in breathing) and hypopnoeas (periods of shallow breathing) each hour, to give your Apnoea-Hypopnoea Index or AHI score. Fewer than 5 is normal, 5-<15 is mild sleep apnoea, 15-<30 is considered moderate and a score 30+ is defined as severe sleep apnoea.

By law, you need to tell DVLA if you are diagnosed with moderate to severe obstructive sleep apnoea with excessive daytime sleepiness. You will be permitted to drive again when your symptoms are under control. To find out more about driving with OSA, please visit the Sleep Apnoea Trust.

Is there a cure for sleep apnoea?

There are several effective treatment approaches for sleep apnoea, depending on what has caused it. If left untreated, sleep apnoea has been linked to increased rates of high blood pressure, stroke, heart disease, diabetes, depression and road accidents, so it’s really important to seek medical help if you think you may be at risk.

Top 5 treatment approaches for obstructive sleep apnoea

1. Healthy lifestyle: exercise and weight loss

If you only have mild sleep apnoea, it might be possible to reduce your symptoms by avoiding triggers like sleeping pills, alcohol and smoking, which can make the condition worse. Alcohol and sleeping pills can lead to deep relaxation of the muscles around the airway, and make collapse more likely, while smoking can irritate the nasal passages and narrow the airway. Use a

If you are overweight, losing weight is likely to reduce the severity of OSA. Regular exercise, and reducing sedentary behaviour, can also improve muscle tone throughout the body, including the airways. Maintaining good sleep habits, by protecting at least 7 hours for sleep each night, and following a regular sleep-wake schedule will also help to improve sleep quality.

2. Sleep apnoea machine: CPAP

The gold standard for moderate to severe sleep apnoea is a machine called a CPAP; a continuous positive airway pressure device. This pumps a continuous flow of oxygen into your airways via a mask worn on the nose or mouth.

It can be hard to get used to wearing an oxygen mask at night at first, but it is something you will gradually get used to if you persist! CPAP is considered the gold standard treatment for restoring good sleep quality in patients with sleep apnoea. Patients who use a CPAP routinely often report dramatic improvements in mood and concentration, as well as a reduction in high blood pressure. If you are struggling to get used to a CPAP device you find uncomfortable or noisy, there are a lot of different options available, so it’s worth speaking to your doctor to find a better fit for you.

3. Strengthening muscle tone: Oropharyngeal therapy, and respiratory training

If your obstructive sleep apnoea is mild to moderate, another approach is to strengthen the muscles you use to breathe, and to improve the muscle tone around the airways so that they are less likely to collapse during the night.

Some studies suggest that regular singing practice, or playing wind instruments such as the didgeridoo could help to reduce sleep apnea. Alternatively, you can practice specific exercises to strengthen the muscles in the tongue and throat; an approach called oropharyngeal or myofunctional therapy. These exercises can include speaking, breathing, blowing, sucking, chewing and swallowing. For example:

• Suck the tongue upwards so it presses all against the hard palate, 20 times.
• Force the back of the tongue against the floor of the mouth while keeping the tip of the tongue in contact with the front incisor teeth, 20 times.
• Elevate the soft palate while saying the vowel “A”, 20 times.

The exercises should be repeated daily for at least 8 weeks. More research is needed to confirm that this approach has long term benefits, but a review of different studies suggested that myofunctional therapy can reduce daytime sleepiness and improve sleep quality in patients with sleep apnoea.

4. Repositioning the jaw: Mandibular Advancement Device

If the airway is compressed by the jaw falling backwards during sleep, an oral device which looks like a gumshield can help. These ‘mandibular advancement devices’ can be fitted by a specialist dentist. Some of these devices are designed to combat snoring, and others are intended to treat both snoring and sleep apnoea. Oral devices are unlikely to be an effective treatment for severe sleep apnoea.

5. Upper airway stimulation

A relatively new approach to treating sleep apnoea is to use an electrical current to stimulate the muscles which keep the airways open. The first approach of this type was to implant a small device under the skin to activate the airway muscles via the hypoglossal nerve during sleep. More recently, regulators in the US have approved a new device ( exciteOSA) which can be worn for 20 minutes during the day to strengthen the muscles in the tongue. It can take 6 weeks to strengthen the airway muscles, so this is not a ‘quick fix’, but has some promising benefits for snoring and sleep apnoea if this is caused by the tongue obstructing the airway. This type of intervention is not yet available on the NHS.

Some people who have structural difficulties breathing, such as because of a deviated septum, or enlarged tonsils, may be offered surgery to tackle their sleep apnoea. In general, surgical approaches to sleep apnoea are seen as a last resort, since they have less reliable outcomes than treatment using CPAP.